Healthcare Provider Details

I. General information

NPI: 1790871598
Provider Name (Legal Business Name): DEREK JEROME PITRE SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7405 N CEDAR AVE 103
FRESNO CA
93720-3838
US

IV. Provider business mailing address

7405 N CEDAR AVE 103
FRESNO CA
93720-3838
US

V. Phone/Fax

Practice location:
  • Phone: 559-261-4100
  • Fax: 559-261-4101
Mailing address:
  • Phone: 559-261-4100
  • Fax: 559-261-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP7009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: